CPC flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Excludes1 convention

An Excludes1 note indicates the two conditions cannot be coded together because they are mutually exclusive; the excluded condition is not coded here and a different code must be used.

Excludes2 convention

An Excludes2 note means the condition is not included in the code but may be reported additionally when documented, because the two conditions can occur together.

Code first instruction

A "code first" note identifies an underlying condition that must be sequenced before the manifestation, such as an underlying disease causing a manifestation.

First-listed diagnosis

For outpatient records, the first-listed diagnosis is the condition chiefly responsible for the services provided and is sequenced first on the claim.

7th character A

The 7th character A in injury codes indicates the initial encounter, meaning the patient is receiving active treatment for the condition.

Z code use

Z codes describe factors influencing health status or encounters for reasons other than disease, such as screening, status after treatment, or occupational exposure.

Diabetic manifestation coding

Diabetes with a manifestation is coded with a combination code for the diabetes and the manifestation, plus an additional code for the type of diabetes when applicable.

Acute MI within 4 weeks

A new myocardial infarction occurring within 4 weeks of a prior MI is coded as an acute MI; an old MI without current symptoms is coded as history of MI.

Hypertension with heart disease

Essential hypertension with heart disease is coded with I11.-, and heart failure is reported with an additional code from I50.- to identify the type.

CKD stage coding

Chronic kidney disease codes N18.- require a documented stage; stage 1 and 2 require clinician documentation, and dialysis status is coded separately with Z99.2.

Sepsis sequencing

Sepsis due to a specified organism is coded with A41.-, sequenced first, with additional codes for localized infection and severe sepsis when documented.

Secondary neoplasm coding

The primary site is coded first and the secondary site second; when the encounter is for metastasis treatment, the secondary site may be first-listed.

Asthma classification

Asthma codes in J45.- reflect severity and control; status asthmaticus is coded J45.901, and acute exacerbation is captured within the J45 code.

Global surgical package

The global surgical package includes preoperative evaluation, the procedure, and routine postoperative care; major surgery has a 90-day global period.

Modifier 50

Modifier 50 indicates a bilateral procedure performed on both sides of the body during the same operative session and is used only when the code does not already specify bilateral.

Modifier 78

Modifier 78 reports an unplanned return to the operating room for a related procedure during the postoperative period, such as treatment of a complication.

Add-on code rule

Add-on codes are reported only with a primary procedure, are never reported alone, and are exempt from multiple procedure payment reduction.

J-code units

HCPCS J-codes report drugs and biologicals; units are calculated from the dosage descriptor, such as per 10 mg, and the number of units billed must match the dose administered.

Modifier 26

Modifier 26 identifies the professional component of a diagnostic service when the physician interprets a test performed and billed by a facility.

MDM level selection

Office E/M level is based on medical decision making or total time; MDM uses problems addressed, data reviewed, and risk, with the level set by the two highest elements.

Total time definition

Total time for E/M includes time on the encounter date for chart review, ordering tests, counseling, and documentation, but excludes separately reported services.

Modifier 25

Modifier 25 is appended to an E/M service when a significant, separately identifiable E/M is provided on the same day as a procedure.

Critical care time

Critical care requires a critically ill patient with imminent deterioration; 99291 covers the first 30-74 minutes and 99292 each additional 30 minutes.

Prolonged service 99417

Code 99417 reports each 15 minutes of prolonged office or outpatient E/M service beyond the highest-level time threshold, reported with the primary E/M code.

Place of service 24

Place of service 24 identifies an ambulatory surgical center, where the facility fee is paid separately from the physician's professional fee.

ASC facility fee

Ambulatory surgical centers report covered CPT® procedures and receive a facility payment separate from the physician's professional fee for the same procedure.

Modifier 57

Modifier 57 is appended to an E/M service when the decision for surgery is made on the same day as a major procedure with a 90-day global period.

Observation code G0378

G0378 reports hospital observation services per hour for the facility, and G0379 reports direct admission to observation care.

ABN and modifier GA

An Advance Beneficiary Notice is signed before a service that may be denied as not medically necessary; modifier GA indicates an ABN is on file.

NCCI edit pairs

National Correct Coding Initiative edits identify code pairs that should not be reported together; modifier 59 or an X modifier applies only when documentation supports a distinct service.

Stark Law

The Physician Self-Referral Law prohibits referrals of designated health services to entities with which the physician has a financial relationship, unless a regulatory exception applies.

CMS-1500 form

The CMS-1500 claim form is used for physician and noninstitutional services, with diagnosis codes listed in priority order and the first-listed diagnosis matching the service reason.